Nursing Elites

1. A nurse is admitting a client who is in labor and at 38 weeks of gestation to the maternal newborn unit. The client has a history of herpes simplex virus 2 (HSV-2). Which of the following questions is most appropriate for the nurse to ask the client?

• A. Have your membranes ruptured?
• B. How far apart are your contractions?
• C. Do you have any active lesions?
• D. Are you positive for beta strep?

Correct answer: C

Rationale: The most appropriate question for the nurse to ask the client in this scenario is whether they have any active lesions. Active lesions from HSV-2 during labor increase the risk of neonatal transmission, which would necessitate a cesarean section to prevent the infant from contracting the virus during delivery. Asking about the presence of active lesions is crucial to determine the appropriate management and precautions needed to protect the newborn. Choices A, B, and D are not as pertinent in this situation and do not directly address the potential risk of neonatal transmission of HSV-2.

2. A nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?

• A. Watching television
• B. Deep breathing exercises
• C. Drinking coffee
• D. Avoiding exercise

Correct answer: B

Rationale: Deep breathing exercises are effective in reducing stress by promoting relaxation and lowering heart rate, making them a recommended technique. Watching television may not actively reduce stress but can serve as a distraction. Drinking coffee, which contains caffeine, may increase anxiety levels. Avoiding exercise can lead to pent-up stress and tension rather than reducing it.

3. What can cause a low pulse oximetry reading?

• A. Hyperthermia
• B. Increased hemoglobin level
• C. Inadequate peripheral circulation
• D. Low altitudes

Correct answer: C

Rationale: Inadequate peripheral circulation can cause a low pulse oximetry reading by limiting blood flow to the area being measured, leading to inaccurate oxygen saturation readings. Hyperthermia (choice A) is an elevated body temperature and does not directly affect pulse oximetry readings. An increased hemoglobin level (choice B) would actually lead to higher oxygen-carrying capacity in the blood, resulting in normal or increased pulse oximetry readings. Low altitudes (choice D) typically do not cause low pulse oximetry readings unless there are other underlying conditions affecting oxygen levels.

4. While caring for a client receiving patient-controlled analgesia (PCA), which of the following interventions should the nurse take?

• A. Encourage the client to use the PCA before dressing changes.
• B. Monitor the client's respiratory status.
• C. Provide oxygen therapy to the client as needed.
• D. Ensure the PCA pump is functioning properly.

Correct answer: A

Rationale: Corrected Rationale: The nurse should encourage the client to use the PCA pump before activities like dressing changes, which are likely to cause pain, to ensure effective pain management. Monitoring the client's respiratory status (Choice B) is important but not the priority in this scenario. Providing oxygen therapy (Choice C) is not a routine intervention for all clients on PCA unless specifically indicated. Ensuring the PCA pump is functioning properly (Choice D) is essential, but encouraging the client to use the PCA before painful activities takes precedence to manage pain effectively.

5. A nurse is caring for a client prescribed digoxin. Which of the following should alert the nurse to possible digitalis toxicity?

• A. Anorexia and weakness
• B. Hyperactivity and hunger
• C. Tachycardia and increased urination
• D. Polyphagia and polydipsia

Correct answer: A

Rationale: Corrected Rationale: Digitalis toxicity is a serious complication of digoxin therapy, particularly in older adults. Early symptoms include anorexia, nausea, and generalized weakness. Anorexia and weakness are common indicators of digitalis toxicity. Hyperactivity, hunger, tachycardia, increased urination, polyphagia, and polydipsia are not typical signs of digitalis toxicity. Monitoring for anorexia and weakness can help detect toxicity early and prevent life-threatening arrhythmias.

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